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Vaccination

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* Differences of immune system of children and adult The normal human no fully active immune system at birth because of immaturity. It relies instead on passively transferred antibodies from the mother. This maternal antibody slowly decreases in concentration and for all practical purposes, has waned by 1 year. The infant own production of antibody begins to be meaningful at 7 or 8 months of age when the total of maternal and infant antibody is low. One has waned and the other is not up to full strength. This is age when many of the infectious disease processes of infancy begin /e.g. otitis media, pneumonia.

* Vaccination

Vaccination Administration of a substance to a person with the purpose of preventing a disease Traditionally composed of a killed or weakened microorganism Vaccination works by creating a type of immune response that enables the memory cells to later respond to a similar organism before it can cause disease

* Early History of Vaccination

Pioneered India and China in the 17th century The tradition of vaccination may have originated in India in AD 1000 Powdered scabs from people infected with smallpox was used to protect against the disease Smallpox was responsible for 8 to 20% of all deaths in several European countries in the 18th century In 1721 Lady Mary Wortley Montagu brought the knowledge of these techniques from Constantinople (now Istanbul) to England Two to three percent of the smallpox vaccinees, however, died from the vaccination itself Benjamin Jesty and, later, Edward Jenner could show that vaccination with the less dangerous cowpox could protect against infection with smallpox The word vaccination, which is derived from vacca, the Latin word for cow.

* Era of Vaccination

English physician Edward Jenner observed that milkmaids stricken with a viral disease called cowpox were rarely victims of a similar disease, smallpox Jenner took a few drops of fluid from a pustule of a woman who had cowpox and injected the fluid into a healthy young boy who had never had cowpox or smallpox Six weeks later, Jenner injected the boy with fluid from a smallpox pustule, but the boy remained free of the dreaded smallpox.

* Era of Vacinnation

In those days, a million people died from smallpox each year in Europe alone, most of them children. Those who survived were often left with blindness, deep scars, and deformities In 1796, Jenner started on a course that would ease the suffering of people around the world for centuries to come. By 1980, an updated version of Jenner vaccine lead to the total eradication of smallpox.

* Early History of Vaccination

* Since Jenner's time, vaccines have been developed against more than 20 infectious diseases

* Vaccination Today

Vaccines have been made for only 34 of the more than 400 known pathogens that are harmful to man. Immunization saves the lives of 3 million children each year, but that 2 million more lives could be saved if existing vaccines were applied on a full-scale worldwide

* Human Vaccines against pathogens

Immunological Bioinformatics, The MIT press.


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Type of Vaccination

* Type of Vaccination
Live Vaccines
Characteristics Able to replicate in the host Attenuated (weakened) so they do not cause disease Advantages Induce a broad immune response (cellular and humoral) Low doses of vaccine are normally sufficient Long-lasting protection are often induced Disadvantages May cause adverse reactions May be transmitted from person to person

* Subunit Vaccines

Relatively easy to produce (not live) Classically produced by inactivating a whole virus or bacterium Heat Chemicals The vaccine may be purified Selecting one or a few proteins which confer protection Bordetella pertussis (whooping cough) Create a better-tolerated vaccine that is free from whole microorganism cells

* Subunit Vaccines: Polysaccharides

Polysaccharides Many bacteria have polysaccharides in their outer membrane Polysaccharide based vaccines Neisseria meningitidis Streptococcus pneumoniae Generate a T cell-independent response Inefficient in children younger than 2 years old Overcome by conjugating the polysaccharides to peptides Used in vaccines against Streptococcus pneumoniae and Haemophilus influenzae.

* Subunit Vaccines: Toxoids

Toxins Responsible for the pathogenesis of many bacteria Toxoids Inactivated toxins Toxoid based vaccines Bordetella pertussis Clostridium tetani Corynebacterium diphtheriae Inactivation Traditionally done by chemical means Altering the DNA sequences important to toxicity

* Subunit Vaccines: Recombinant

The hepatitis B virus (HBV) vaccineOriginally based on the surface antigen purified from the blood of chronically infected individuals. Due to safety concerns, the HBV vaccine became the first to be produced using recombinant DNA technology (1986)Produced in bakers’ yeast (Saccharomyces cerevisiae)Virus-like particles (VLPs) Viral proteins that self-assemble to particles with the same size as the native virus. VLP is the basis of a promising new vaccine against human papilloma virus (HPV)MerckIn phase III For more information se: http://www.nci.nih.gov/ncicancerbulletin/NCI_Cancer_Bulletin_041205/page5

* Genetic Vaccines

Introduce DNA or RNA into the host Injected (Naked) Coated on gold particles Carried by viruses vaccinia, adenovirus, or alphaviruses bacteria such as Salmonella typhi, Mycobacterium tuberculosis Advantages Easy to produce Induce cellular response Disadvantages Low response in 1st generation

* Type of Vaccination

Live attenuated Vaccine OPV Measles Rubella Mumps BCG Varicella Vaccine
Inactivated organism or their products Diphtheria Tetanus Pertussis( whole cell/acellular) Hepatits Avaccine Hepatitis B Pneumococcal Polysaccharide vaccine Influenza IPV Hib

* Passive Immunity

Transfer of antibody produced by one human or other animal to another Transplacental most important source in infancy Temporary protection

* Sources of Passive Immunity

Almost all blood or blood products Homologous pooled human antibody (immune globulin) Homologous human hyperimmune globulin Heterologous hyperimmune serum (antitoxin)



* IMMUNOGLOBULIN PREPARETION Normal human Ig. Normal human Ig is an antibody-rich fraction, obtained from a pool of at least 1000 donors. The preparation should contain at least 90% intact IgG; it should be as free as possible from IgG aggregates; all IgG sub-classes should be present; there should be a low IgA concentration; the level of antibody against at least two bacterial species and two viruses should be ascertained Normal human Ig used to prevent measles in highly susceptible individuals and to provide temporary protection /up to 12 weeks/ against hepatitis A infection. Live vaccines should not normally be given for 12 weeks after an injection of normal human Ig.

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Vaccine Preventable Diseases

An infectious disease for which an effective preventive vaccine exists. If a person dies from it, the death is considered a vaccine-preventable death.

TUBERCULOSIS

DIPHTHERIA

PERTUSSIS

POLIOMYELITIS

MEASLES

TETANUS

FULLY IMMUNIZED CHILD

A child who received One dose of BCG, Three doses of DPT and OPV, One dose of measles before one year of age. This gives a child the best chance for survival.


ControlReduction of prevalence or incidence of disease to lower acceptable level. EliminationEradication of disease from a large geographic region or political jurisdictionEither reduction of infectious disease’s prevalence in regional population to zero or reduction of global prevalence to a negligible amount.EradicationTermination of all transmissions of infection by extermination of infectious agent through surveillance and containment.Reduction of infectious disease’s prevalence in global host population to zero.

EXPANDED PROGRAMME ON IMMUNISATION (EPI) EPI launched in 1974 Build on smallpox infrastructure Targeted 6 diseases EPI progressively adopted by all countries Universal by early 1098s

Addition to EPI Yellow fever in 1988 For endemic countries only : 33 in Africa, 11 in S. America. Given with measles vaccine Hepatitis B in 1992 In high seroprevalence countries by 1995 In all countries by 1997 Haemophilus influenzae type b (Hib) 1998 : based on disease burden and capacity 2006 : all countries. ( lack of data should not be obstacle)

3 slides of coverage fm unicef

3 slides of coverage fm unicef

COMPONENTS of program

1. Immunization of pregnant women against tetanus. 2. Immunization of children in their first year of life against 6 VPDs.

3) Immunisation in preterm infants All vaccines except Hepatitis B If BW < 2Kg & mother HBsAg negative :- postpone till baby attaines 2kg wt or 2 mths of age. If BW < 2Kg & mother HBsAg positive :- give vaccine + immunoglobulin.

4) Children receiving corticosteroids Children receiving corticosteroids at the dose of 2 mg/kg/day for more than 14 days should not receive live virus vaccines until steroid has been discontinued for at least 1 month.

Tetanus toxoid

Intramuscular – upper arm – 0.5 mlPregnancy – 2 doses - 1st dose as early as possible and second dose after 4 weeks of first dose and before 36 weeks of pregnancy Pregnancy – booster dose (before 36 weeks of pregnancy) – If received 2 TT doses in a pregnancy within last three years. Give TT to woman in labour, if she has not received TT previouslyTT booster for both boys and girls at 10 years and 16 yearsNo TT required between two doses in case of injury


BCG
At birth or as early as possible till one year of age 0.1 ml (0.05ml until one month of age) Intra-dermal Left upper arm

Hepatitis B

Birth dose – within 24 hours of birth 0.5 ml IntramuscularAntero-lateral side of mid-thighRest three doses at 6 weeks, 10 weeks and 14 weeks

OPV
Zero dose – within first 15 days of birth2 drops OralFirst, second and third doses at 6, 10 and 14 weeks with DPT-1, 2 and 3OPV booster with DPT booster at 16-24 months

DPT
Three primary doses at 6, 10 and 14 weeks with OPV-1, 2 and 3 0.5 ml Intra-muscular Antero-lateral side of mid-thigh One booster at 16-24 m with OPV booster (antero-lateral side of mid-thigh) and second booster at 5-6 years (upper arm)

Measles

At 9 completed months to 12 monthsGive up to 5 years if not received at 9-12 months ageSecond dose at 16-24 months (select states after catch-up campaign) – Measles Containing Vaccine0.5 mlSub-cutaneousRight upper armAlong with Vitamin A (1st dose) – 1ml (1 lakh IU) - oral

Constraints Illiteracy Non uniform coverage Poor implementation Poor monitoring High drop outs Declining coverage in some major states Over reporting Poor injection safety Reorientation of staff being not carried out

Vacany of staff at field level not filled Poor surveillance of vaccine preventable diseases Poor vaccine logistics Poor maintainance of equipments Extra ordinary emphasis on polio vaccine


Route of Administration

* Route of Adminstration

Oral
OPV
Intradermal
BCG, Rabies
Subcutaneous
Measles, Mumps, Rubella, MMR, IPV, Pneumoccocal, Influenza
Intramuscular
DPT, DT Tetanus, HepatitisA, HepatitisB, Pneumococcal, Rabies, Hib, Influenza

* Site of Administration

Intradermal
Over the insertion of left deltoid muscle
Subcutaneous
Anterolateral aspect of the thigh or the upper arm
Intramuscular
Anterolateral aspect of the thigh in infants and deltoid muscle in older children or adult.

* Who should not be vaccinated?

Allergy Fever HIV infection Immunodeficiency IG administration
Neurological disorder Prematurity Reactions to Previous vaccine Simultaneous administration of Vaccines Thrombocytopenia

* Allergy

A. Allergic Reactions to Egg-related antigens Yellow fever and influenza vaccines do contain egg proteins and rarely induce immediate allergic reactions. Skin testing is recommended before administration with an history of allergic to egg MMR- Even those with severe hypersensitivity are at low risk of anaphylaxis.

* Allergy

B. Antibiotic-induced allergic reactionDelayed type local reaction 48-96 hours afterwards and is usually minorIPV and OPV – streptomycin, neomycin and polymyxin BMMR and varicella vaccine-neomycin

* Allergy

C. Gelatin- MMR, Varicella vaccine

* Fever

Low-grade fever or mild illness is not a contraindication for vaccination Children with moderate or severe febrile illnesses can be vaccinated as soon as they are recovering and no longer acutely ill

* Vaccination in Pregnancy

Risk to a developing fetus from vaccination of the mother during pregnancy is mostly theoretical Only smallpox vaccine has ever been shown to injure a fetus The benefits of vaccinating usually outweigh potential risks

* Vaccination in Pregnancy

Inactivated vaccinesRoutine (influenza)Vaccinate if indicated (hep B, Td, mening, rabies)Vaccinate if benefit outweighs risk (all other)Live vaccine – do not administerException is yellow fever vaccine

* HIV Infection

No BCG OPV is Contraindicated in household contact, in recipient ( asymptomatic or symptomatic) IPV for these children and household contacts MMR vaccination should be considered for all asymptomatic and to all symptomatic HIV-infected persons who do not have evidence of severe immunosuprresion or measles immunity Pneumococcal vaccine, Hib, DTP (or DTaP), Hepatitis B vaccine, Influenza vaccines are all indicated

* Immunosupression

No live viral vaccines and BCG. IPV for these patients, their siblings and their household contacts No live vaccine (except varicella) until six months after immunosuppressive therapy

* Neurological disorder

Progressive developmental delay or changing neurological findings (e.g. infantile spasm) - defer pertussis immunization Personal history of convulsionsRecent seizures - defer pertussis immunization Conditions predisposing to seizures or neurological deterioration (e.g. tuberous sclerosis) - defer pertussis immunization

* Reactions

Severe Reactions to DTP Insonable cry lasting more than 3 hrs with 48 hrs of dose Seizure with 3 days Severe local reactions Family hx of adverse event Not a contraindication, but consider carefully the benefits and risks, if need to vaccinate can use acellular DTP for less reactions

* Reactions

GBS with 6 weeks after a dose of DTP Again based on risks and benefits for further dose of DTP and risk of GBS recurrence.



* Reactions
Contraindication for further dose of DTP encephalopathy within 7 days of a dose of DTP

* VACCINE REACTIONS

Common, minor reactions vaccine stimulates immune system settle on their own warn parents and advise how to manage Rare, more serious reactions anaphylaxis (serious allergic reaction) vaccine specific reactions

* RARE, MORE SERIOUS REACTIONS

BCG
Hib
HepB
Measles/ MMR/MR
Suppurative lymphadenitis BCG osteitis Disseminated BCG infection
1 in 1000 to 1 in 10 000 1 in 3000 to 1 in 100 million ~1 in 1 million
None known
Anaphylaxis
1 in 6-900 000
Febrile seizures Thrombocytopaenia (low platelets) Severe allergic reaction Anaphylaxis Encephalopathy
1 in 3000 1 in 30 000 ~1 in 100 000 ~1 in 1 million <1 in 1 million
Reaction
Incidence

* RARE, MORE SERIOUS REACTIONS (2)

Tetanus
Pertussis (DTP- whole cell)
Reaction
Incidence
Polio (OPV)
Vaccine associated paralytic poliomyelitis Risk is higher for first dose, adults, and immunocompromised
1 in 2.4-3.3 million doses 1 in 750 000 first dose compared to 1 in 5.1 million for subsequent doses
Brachial neuritis Anaphylaxis
0.5-1 in 100 000 1 in 100 000 to 1 in 2 500 000
Persistent inconsolable screaming Seizures Hypotonic, hyporesponsive episode (HHE) Anaphylaxis Encephalopathy (Note: Risk may be zero)
1 in 15 to 1 in 1000 1 in 1750 to 1 in 12 500 1 in 1000 to 1 in 33 000  1-6 in million 0-1 in 1 million

* Simutaneous administration of Vaccine

A theoretical risk that administration of multiple live virus vaccine: OPV, MMR, and varicella ) within 28 days of one another if not given on the same day will result in a sub optimal immune response No data to substantiate this

* Vaccine Cold Chain

Maintaining proper vaccine temperatures during storage and handling to preserve potency The success of efforts against vaccine-preventable diseases is attributable in part to proper storage and handling of vaccines. Exposure of vaccines to temperatures outside the recommended ranges can affect potency adversely, thereby reducing protection from vaccine-preventable diseases


* Recommended Storage Temperatures


Table 5: Vaccination Schedule for Infants and Children 2012 Age Type of vaccine 0-1 Week OPV0 dose , HepB1 , BCG 2 Months OPV1 , PENTA1,ROTA1 4 Months OPV2 , TETRA1,ROTA2 6 Months OPV3 , PENTA2,ROTA3 9 Months Measles + VIT A 15 Months MMR (Measles , Mumps , Rubella) 18 Months TETRA2, OPV First Booster dose + VIT A 4-6 Years DPT , OPV Second Booster dose + MMR2
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Table 6: National Immunization Schedule for Infants and Children 2015 Age Type of vaccine 0-1 Week HepB1 , BCG + OPV0dose 2 Months HEXA 1,ROTA1 ,PREV13-1+OPV1 4 Months HEXA2,ROTA2,PREV13-2 + OPV2 6 Months HEXA3,ROTA3,PREV13-3 + OPV3 9 Months Measles + VIT A 15 Months MMR(Measles , Mumps , Rubella) 18 Months PENTA (DTP+IPV+Hib ) OPV + VIT A 4-6 Years TETRA (DTaP +IVP ) + OPV + MMR
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